The document provides guidance on triaging sick children based on an ABCDE (Airway, Breathing, Circulation, Coma/Convulsions, Dehydration) assessment and identifying those with emergency signs who require immediate emergency treatment; it describes how to assess each component, signs that indicate an emergency, and steps for managing airway and breathing emergencies and providing life support.

1. General Principles of care

2. The Lancet Global Health , 2019
 Pneumonia , Diarrhea remains
two most common causes of
mortality in children aged 1-59
months
 Many of these deaths may be
prevented by early referral of
sick children to health facility
and providing appropriate
treatment.
ALL-CAUSE AND CAUSE-SPECIFIC UNDER 5 MORTALITY IN INDIA( 2000 – 15)

3. First step is triage and providing treatment to children with emergency signs
Triage is the process of rapidly screening all sick children on their arrival in
hospital to place them in one of the following categories:
E Emergency
P Priority
Q Queue (non-urgent)
STEPS IN THE MANAGEMENT OF SICK CHILDREN

4. • HISTORY & EXAMINATION
• POINT OF CARE/BEDSIDE INVESTIGATIONS, if required
List and consider DIFFERENTIAL DIAGNOSES
• Plan and begin INPATIENT TREATMENT (including supportive care)
• Laboratory investigations, x-ray etc, if required
Decide the need for HOSPITALIZATION/REFERRAL
TRIAGE
Check for emergency signs
EMERGENCY TREATMENT
CHART 1.1: STEPS IN THE MANAGEMENT OF CHILDREN BROUGHT TO HOSPITAL

5. • Plan and begin INPATIENT TREATMENT (including supportive care)
• Laboratory investigations, x-ray etc, if required
DISCHARGE
Arrange continuing care
and FOLLOW-UP at
hospital or in the
community
• CONTINUE Management
• COUNSEL and
• PLAN DISCHARGE
IMPROVEMENT
• REVISE TREATMENT
• TREAT COMPLICATIONS
(Refer if cannot be treated)
NOT IMPROVING OR NEW
COMPLICATION
MONITOR for
• Response to treatment
• Complications
MONITOR for
• Response to treatment
• Complications
CHART 1.1: STEPS IN THE MANAGEMENT OF CHILDREN BROUGHT TO HOSPITAL
(CONT.)

6. Many deaths in hospital occur within 24hrs of admission.
Failure to recognize critically unwell children when they first present to hospital
leads to delayed resuscitation and increased risk of death.
Effective TRIAGE is key to identify the critically unwell child on arrival so that
appropriate emergency treatment can be initiated on time.
INTRODUCTION

7. The word “triage” means sorting.
Sick children on their arrival in hospital are categorized in one of
the following three categories:
Emergency
Priority
Queue (non-urgent)
Triaging improves survival of sick children by
identifying children requiring emergency
treatment .
WHAT IS TRIAGE?

8.  Triaging should be quick
 HCW must learn to assess
several signs at the same
time.
 Adherence to infection control measures (Use of N-95 mask, gloves,
head shield, hand washing etc.) by all HCW involved in triaging is
important
TRIAGING PROCESS

9. The ABCD concept
To quickly assess the patient for serious illness or injury, assess emergency signs, which
relate to the Airway-Breathing-Circulation/Convulsions/Consciousness-Dehydration.
You can easily remember them as “ABCD”.
A: Airway
B: Breathing
C:Circulation/Convulsions/Consciousness
D: Dehydration
TRIAGING PROCESS

10. AIRWAY
AND
BREATHING
 Not breathing or Gasping
or
Obstructed breathing
or
Central cyanosis
or
Severe respiratory distress
ASSESS TREAT
 Do not move neck if cervical spine injury
possible
 Keep the child warm
ANY SIGN
POSITIVE
IF NOT BREATHING OR GASPING
 Manage airway
 Start life support
OBSTRUCTED BREATHING / CENTRAL
CYANOSIS OR SEVERE RESPIRATORY
DISTRESS
 Manage airway
 Give oxygen
 Make sure child is warm
ABCD
Contd…
TRIAGE OF ALL SICK CHILDREN – AIRWAY &
BREATHING

11. ASSESS TREAT
 Do not move neck if cervical spine injury
possible
 Keep the child warm
CIRCULATION
Cold hands with:
 Capillary refill longer than
3 seconds, and
 Weak and fast pulse
IF POSITIVE
ABCD
IF SEVERE ACUTE MALNUTRITION
 Give IV glucose
 Insert IV line and give fluids slowly
 If the child has any bleeding, apply
pressure to stop the bleeding. Do not
use a tourniquet.
 Give Oxygen
 Make sure child is warm
IF NO SEVERE ACUTE MALNUTRITION
Insert IV line* and begin giving fluids
rapidly
Check for
severe acute
malnutrition
Contd…
TRIAGE OF ALL SICK CHILDREN - CIRCULATION

12. ASSESS TREAT
ABCD
Contd…
COMA/
CONVULSING
 Coma or
 Convulsing (now)
- Manage airway
- Position the unconscious child (if head
or neck trauma is suspected, stabilize
the neck first)
- Give Oxygen
- Check and correct hypoglycaemia
- Give IV calcium if infant <3 months
- If convulsion continue, give anti-
convulsant
IF COMA OR
CONVULSING
TRIAGE OF ALL SICK CHILDREN – COMA/ CONVULSION
 Do not move neck if cervical spine injury
possible
 Keep the child warm

13. Check for severe
acute malnutrition
Contd…
SEVERE
DEHYDRATION
(ONLY IN CHILD
WITH DIARRHOEA)
Diarrhoea plus any
two of these
Lethargy
Sunken eyes
Very slow skin pinch
- Make sure child is warm
•IF NO SEVERE ACUTE MALNUTRITION
- Insert IV line and begin giving fluids
(RL/NS) rapidly
•IF SEVERE ACUTE MALNUTRITION
- Do not give IV fluids, give ORS#
- Proceed immediately to full
assessment and treatment
DIARRHOEA plus
TWO SIGNS
POSITIVE
TRIAGE OF ALL SICK CHILDREN - DEHYDRATION
ASSESS TREAT
ABCD
 Do not move neck if cervical spine injury
possible
 Keep the child warm

14. IF THERE ARE NO EMERGENCY SIGNS LOOK FOR PRIORITY SIGNS:
These children need prompt assessment and treatment
PRIORITY SIGNS
• Tiny baby (<2 months)
• Temperature very high
• Trauma or other urgent surgical
condition
• Pallor (severe)
• Poisoning
• Pain (severe)
• Respiratory distress
• Restless, continuously irritable, or
lethargic
• Referral (urgent)
• Malnutrition: Visible severe wasting
• Oedema of both feet
• Burns (major)
Chart 2.1: Triage of all sick children (cont.….)
NON-URGENT: Proceed with assessment and further treatment according to the child’s priority.
Note: If a child has trauma or other surgical problems,
get surgical help or follow surgical guidelines.

15. TRIAGE- AIRWAY & BREATHING
ASSESSMENT

16. Is the Airway Obstructed?
If the child is not breathing, or if the child has severe
respiratory distress, look for any obstruction to the
flow of air?
More common in -
Foreign body aspirations
Unconscious children due to backward fall of tongue
Trauma
AIRWAY & BREATHING (ABCD)

17. Is the Child Breathing?
To assess whether the child is breathing there
are three things you must do:
Look: If active, talking, or crying, the child is obviously
breathing. If not
Listen: Listen for any breath sounds. Are they normal?
Feel: Can you feel the breath at the nose or mouth of the
child?
AIRWAY & BREATHING (ABCD)

18. Is the child cyanosed?
Cyanosis occurs when there is an abnormally low
level of oxygen in the blood.
To assess for central cyanosis, look at the mouth
and tongue. A bluish or purplish discoloration of
the tongue and the inside of the mouth indicates
central cyanosis.
 This sign may be absent in a child who has severe
anaemia as they do not enough hemoglobin to
manifest cyanosis.
ASESS AIRWAY & BREATHING

19.  Is there difficulty in breathing while talking, eating or breastfeeding?
 Is the child breathing very fast, has severe lower chest wall in-drawing, or
using the auxiliary muscles for breathing which cause the head to nod or
bob with every inspiration? The latter is particularly seen in young infants.
 Is oxygen saturation (SpO2) less than 90%?
ASESS AIRWAY & BREATHING

20. CHECK OXYGEN SATURATION OF ALL SICK
CHILDREN

21.  A harsh noise on breathing in (inspiration) is called stridor,
 A short noise when breathing out (expiration) in young infants is called grunting.
 Both noises are signs of severe respiratory problems
IS THERE ANY ABNORMAL RESPIRATORY NOISES?

22. One or more of the following signs:
Laboured or very fast breathing (RR >70/min)
Severe lower chest wall indrawing
Use of auxiliary muscles
Head nodding
Inability to feed because of respiratory problems
Abnormal respiratory noises (stridor, grunting)
SpO2 (oxygen saturation) <90%
SEVERE RESPIRATORY DISTRESS

23. MANAGEMENT OF EMERGENCY SIGNS – AIRWAY
& BREATHING
ABCD Concept
(“E” Signs)
A: Airway
B: Breathing
C: Circulation /convulsions/
consciousness
D: Dehydration
*20s
 Start treatment without delay.
 Call for help.
 Carry out point of care emergency
investigations
 Proceed immediately to assess,
diagnose and treat the underlying
condition.
 Hospitalize all children with
emergency signs and observe till
stabilization.
 Reassess (ABCD) frequently for
emergency signs (during & after
emergency treatment).

24. Chart 2.1: Triage of all sick children
• Not breathing or Gasping
or
•Obstructed breathing
or
•Central cyanosis,
or
•Severe respiratory distress
•IF NOT BREATHING OR GASPING
Manage airway
Start life support
•OBSTRUCTED BREATHING / CENTRAL
CYANOSIS OR SEVERE RESPIRATORY
DISTRESS
- Manage airway
Give oxygen
Make sure child is warm
AIRWAY
AND
BREATHING
ASSESS
ABCD
Treat
Do not move neck if cervical spine injury
possible. Keep the child warm.
ANY SIGN
POSITIVE

25. Gently tap the victim
Ask loudly, “Are you okay?”
Call the child's name if you know it.
If the child is responsive, he or she will answer,
move, or moan.
Quickly check to see if the child has any injuries
CHECK FOR RESPONSE

26. Three-member ERS team making the
triangle of resuscitators with add on
responsibilities can provide life support:
Role 1:Airway & breathing (act as leader)
Role 2: Compressor to alternate with
member 3
Role 3:Automated external defibrillator
(AED) or defibrillator/administer
medication/assists
PROVIDE LIFE SUPPORT

27. Chart 2.2: Providing Life Support
Limit Persons to ERS
team
• Look for breathing
• Check central pulse (5-10 seconds)
All HCW providing emergency care –
Don PPE
Unresponsive child- Shout for help/Activate
Emergency response teamwithin 5 seconds
For palpating carotid pulse , slide 2-3 fingers from
midline in the neck to one side( side of observer) in
the groove between the trachea and the muscles or
feel for Brachial Pulse on medial side of upper arm.

28. Chart 2.2: Providing Life Support
Limit Persons to ERS
team
- No breathing /Gasping: Provide rescue breathing
with bag & mask: Give 1 breath every 3 seconds
(Use bag & mask device with filter and tight seal
if COVID is a possibility or could not be ruled out)
- Reassess pulse & add chest compressions, if
pulse remains <60/min despite adequate
oxygenation
• Look for breathing
• Check central pulse (5-10 seconds)
All HCW providing emergency care –
Don PPE
Definite Pulse
Unresponsive child- Shout for help/ Activate
Emergency response teamwithin 5 seconds

29. Chart 2.2: Providing Life Support
Limit Persons to ERS
team
• Start CPR: Begin cycles of 15 CHEST COMPRESSIONS and 2 BREATHS
Reassess for pulse every 2 min
• Look for breathing
• Check central pulse (5-10 seconds)
All HCW providing emergency care –
Don PPE
No Pulse
• If available, attach cardiac monitor, analyze rhythm, and use defibrillator ifrhythm shockable
Unresponsive child- Shout for help/ Activate
Emergency response teamwithin 5 seconds

30. Chest Compression-Thumb
Technique (In Infant)
2-Finger Technique
(In Infant)
Chest Compression for the Child
(1 year or above)
High quality CPR
 Rate at least 100-120/min
 Compression depth of at least 1/3 AP diameter of chest, about
1.5 inches (4 cm) in infants and 2 inches (5 cm) in children
 Allow complete chest recoil after each compression
 Minimize interruptions in chest compressions
 Avoid excessive ventilation
CHEST COMPRESSION DURING LIFE SUPPORT

31. Compress the lower half of the sternum just below the
nipple line avoiding xiphisternum
CHEST COMPRESSION IN INFANTS

32. PUSH HARD- PUSH FAST
Shoulders directly on the
sternum
Arms stiff
Elbows locked
CHEST COMPRESSION IN OLDER CHILDREN

33. Compression-to-ventilation ratio of 15:2 is
recommended.
CHEST COMPRESSION

34. Chart 2.2: Providing Life Support
Limit Persons to ERS
team
• Start CPR: Begin cycles of 15 CHEST COMPRESSIONS and 2 BREATHS
Reassess for pulse every 2 min
• Look for breathing
• Check central pulse (5-10 seconds)
All HCW providing emergency care –
Don PPE
No Pulse
• If available, attach cardiac monitor, analyze rhythm, and use defibrillator ifrhythm shockable
Unresponsive child- Shout for help/ Activate
Emergency response teamwithin 5 seconds

35. Chart 2.2: Providing Life Support
• Spontaneous breathing efforts present
• Stop bag & mask
• Put in recovery position
• Give oxygen
• Continue further assessment
• Stop chest compression
• Continue ventilation for 2 mints
• Assess for spontaneous breathing efforts
• No or poor respiration
• Continue bag & mask ventilation with oxygen,
1 breath every 3 sec
• Reassess every 2 min
≥60/min
• Continue chest compression, Continue
ventilation
• Put IV/IO line
*If only one rescuer available give 30 compression
and 2 breaths per cycle
Reassess for pulse every 2 min
<60/min
No pulse palpable
<60/min
• Consider transfer to ICU setting
• Use defibrillator, if rhythm shockable**
• Call for help, consider advanced ventilation if
available
• Start medication***
***Give epinephrine every 3-5 minutes; 0.01
mg/kg (0.1 ml/kg of 1:10000 concentration); max.
of 1 mg (10 ml)
**1st dose 2 J/ Kg; second dose 4 J/Kg; subsequent
dose >= 4 J/kg maximum 10J/Kg
Pulse palpable , Count pulse rate

36. MANAGE AIRWAY , BAG & MASK
VENTILATION

37. Neutral Position
in an Infant
Sniffing
Position to
Open Up
Airway in a
Child (Chin Up)
POSITIONING TO IMPROVE THE AIRWAY

40. Jaw Thrust without
Head Tilt
Presence of head or neck trauma
POSITIONING TO IMPROVE THE AIRWAY

41. 1. Correct size and position
2. Mask too large, overlaps the
chin
3. Mask too small, nostrils not
covered
4. Mask too large, overlap with
eyes
 Before use, check the bag and valve
by closing the patient’s side of
connection with your thumb and
attempt to expel air from the bag
 It is important for the mask to be the
correct size for the child; it must
completely cover the mouth and nose
without covering the eyes or
overlapping the chin.
VENTILATE WITH BAG AND MASK

42. Self Inflating Bag
 If the child is not breathing or
breathing is inadequate (as judged
by insufficient chest movements and
inadequate breath sounds) even
after management of the airway,
ventilate with a self-inflating bag
and mask.
 Wherever there is risk of COVID,
use bag-mask device with filter and
tight seal.
VENTILATE WITH BAG AND MASK

43. Self Inflating Bag
 Use only the force and tidal volume necessary to cause
the chest to rise visibly.
 Reservoir and oxygen (5-6 L/min) should be connected
to the self-inflating bag during resuscitation.
 If oxygen is not available, use room air for
resuscitation. With room air 21% oxygen is delivered,
but by using oxygen source with reservoir 60% to 90%
oxygen can be delivered.
If signs of circulation are present but spontaneous breathing is
absent, continue bag and mask ventilation at a rate of 20 breaths/
minute for a few minutes and see if child revives and starts to
breathe spontaneously. If bag and mask ventilation is prolonged it
can cause gastric inflation, which can be relieved by nasogastric
tube.
VENTILATE WITH BAG AND MASK

44. Bag and Mask
Ventilation E-C
clamp technique
VENTILATE WITH BAG AND MASK

45. When two persons are available and only ventilation is required, use
this method.
With the two-
provider
technique, one
person should
hold the mask
with both hands,
while the other
person bags the
patient
An alternative
method is for the
mask holder to
apply pressure to
the mask while
using four finger
to apply jaw lift
Actions to be taken if effective ventilation
is not achieved
 Reapply mask & reposition the head
 Suction the throat and keep mouth slightly
open
 Increase the pressure
 Use endotracheal intubation if skill available
VENTILATE WITH BAG AND MASK

46. Foreign body should be suspected in cases of sudden respiratory distress
associated with coughing, gagging, stridor, cyanosis, or wheezing.
A child with a history of aspiration of a foreign body who shows increasing
respiratory distress is in immediate danger of choking.
Attempts to remove the foreign body should be made instantly.
MANAGEMENT OF AIRWAY IN A CHOKING
CHILD (FOREIGN BODY ASPIRATION WITH
INCREASING RESPIRATORY DISTRESS)

47. The treatment differs depending on whether there is a foreign body
causing respiratory obstruction or some other cause for the
obstruction or respiratory distress.
If child is able to cough or cry it indicates partial obstruction.
Encourage the child to cough, consider immediate referral where
bronchoscopy facility is available.
If a foreign body is causing the complete obstruction, it is life
threatening and needs immediate interventions. Different methods
are used for clearing up the foreign body in infants and children.
MANAGING AIRWAY OF A CHOCKING CHILD

48. Slapping the back
to clear airway
obstruction in a
choking child
 Lay the infant on your arm or thigh in a
head down position and support the
head by firmly holding the jaw.
 Give 5 blows to the infant’s back with
heel of hand between the shoulder
blades.
 If obstruction persists, turn infant over
and give 5 chest thrusts with 2 fingers,
one finger breadth below nipple level
in midline.
 If obstruction persists, check infant’s
mouth for any foreign body which can
be removed.
 If necessary, repeat sequence until the
foreign body is expelled or the patient
becomes unconscious. If he becomes
unconscious start CPR.
RELEVING COMPLETE AIRWAY OBSTRUCTION
IN INFANT

49. The child may be sitting or
standing.
Stand or kneel behind the child
and encircle his torso by putting
both arms directly under axillae
Place the thumb side of one fist
against the victim’s abdomen in
the midline slightly above the
navel and well below the tip of
the xiphoid process.
Heimlich maneuver in a
choking older child
MANAGEMENT OF CONSCIOUS CHILD :
ABNORMAL THURSTS (HEIMLICH MANEUVER)
≥ 1 YEAR

50. Place the other hand over the fist and pull upwards
into the
abdomen, repeat this Heimlich maneuvers 5 times.
If the obstruction persists, check the child’s mouth
for any foreign body which can be removed.
If necessary, repeat this sequence until the foreign
body is expelled . Start life support if child becomes
unconscious.
Heimlich maneuver in a choking
older child
MANAGEMENT OF CONSCIOUS CHILD :
ABNORMAL THURSTS (HEIMLICH MANEUVER) ≥
1 YEAR

51. Clinical signs spO2 Oxygen therapy
Only respiratory distress <90% Yes
Other emergency signs <94% Yes, till emergency signs
persists.
If pulse oximeter not available or does no pick saturation , oxygen therapy should be
guided by clinical signs and should be continued till emergency signs persists.
For all children who have any problem with their airway or breathing,
always give oxygen first, while you continue to assess for other problems.
GIVE OXYGEN

52. When a pulseoximeter is not available or pulseoximeter does not pick saturation
(shock, hypothermia) , the necessity for oxygen therapy should be guided by
clinical signs and should be continued till emergency signs persists.
 Oxygen therapy can be stopped when a child no longer has emergency signs and
maintains a peripheral capillary oxygen saturation ≥90% in room air.
GIVE OXYGEN

53. To assess if a child has a circulation problem:
Does the child have warm hands ?
-To assess the circulation, take the child’s hand in your own.
If it feels warm, the child has no circulation problem and you
do not need to assess capillary refill or pulse.
-If the child’s hands feel cold, you will need to assess the
capillary refill
ASSESS CIRCULATION

54. Is the pulse weak and fast ?
 Check the central pulse (a pulse
nearer to the heart).
 Pulse is fast if rate is >160/min
in an infant and >140/min in
children above 1 year.
ASSESS CIRCULATION
Children with any sign of impaired circulation, i.e. cold extremities, or
prolonged capillary refill or a weak and fast pulse, should be prioritized for
full assessment and treatment and reassessed within 1 hour.

55. SHOCK
If the child has cold hands, a CRT ≥ 3 seconds, and a fast &
weak pulse, then he or she is in shock.
 Establish IV access at an appropriate site (or intraosseous access)
 Take blood samples for emergency laboratory tests
 Administer a fluid bolus of 20 ml/kg* of isotonic crystalloid solution
(RL/NS over 30-60 minutes) under close monitoring every 5-10
minutes.
*10 ml/kg if cardiogenic shock is a possibility or has febrile illness or severe
anemia . May be repeated if partial improvement

56. BLOOD PRESSURE AND SHOCK
 It is not recommended to check blood pressure to assess for shock during the ETAT
because of two reasons:
 Low blood pressure is a late sign in children and may not help to identify early
(compensated) shock cases.
 Normal BP readings will not exclude compensated type of shock.
However it should be monitored once triage is done as a part of clinical assessment
(wherever high or low blood pressure is suspected)

57. Chart 2.1: Triage of all sick children
Cold hands with:
• Capillary refill longer than
3 seconds, and
• Weak and fast pulse
• Not breathing or Gasping
or
• Obstructed breathing
or
• Central cyanosis,
or
• Severe respiratory distress
• IF NOT BREATHING OR GASPING
 Manage airway
 Start life support
• OBSTRUCTED BREATHING / CENTRAL CYANOSIS OR
SEVERE RESPIRATORY DISTRESS
- Manage airway
 Give oxygen
 Make sure child is warm
• IF NO SEVERE ACUTE MALNUTRITION:
- Insert IV line* and begin giving fluids rapidly
• IF SEVERE ACUTE MALNUTRITION
• Give IV glucose
• Insert IV line and give fluids slowly
• If the child has any bleeding, apply pressure to stop the
bleeding. Do not use a tourniquet.
• Give oxygen
• Make sure child is warm
Check for severe
acute malnutrition
AIRWAY
AND
BREATHING
ASSESS
ABCD
Treat
Do not move neck if cervical spine injury possible. Keep
the child warm.
CIRCULATION
ANY SIGN
POSITIVE
IF POSITIVE
*If not able to insert peripheral IV, insert an external jugular or
intraosseous line

58.  Children with any sign of impaired circulation, i.e. cold
extremities, or prolonged capillary refill or a weak and fast pulse,
should be prioritized for full assessment and treatment
 They all should be reassessed within 1 hour as disease may be
progressive.
ASSESS CIRCULATION

59. If the child has cold hands, a CRT ≥ 3 seconds, and a fast &
weak pulse, then he or she is in shock.
Treatment of shock requires teamwork and following actions
need to be started simultaneously:
 If the child has any bleeding, apply pressure to stop the
bleeding (do not use tourniquet)
 Give oxygen to keep Spo2 >94%
 Make sure the child is lying supine, head not elevated.
EMERGENCY TREATMENT FOR SHOCK

60. Administer intravenous fluids during initial resuscitation of all
forms of shock however remember cardiogenic shock require
alternative therapies.
Volume expansion is best achieved with isotonic crystalloid
solutions such as Ringer's lactate (RL) or normal saline (NS) as
they are easily available and effectively expand the intravascular
volume.
INITIAL FLUID THERAPY IN SHOCK

61. As only approximately one fourth of administered solution remains in
the intravascular compartment, hence adequate quantity of
crystalloid solution must be administered in hypovolemic children.
FLUID THERAPY IN SHOCK

62. Large rapid bolus may cause problem in febrile children,
children who are malnourished and children with
cardiogenic shock where slow and careful monitoring is
critical.
Colloid solutions (e.g. hemoccel, 5% albumin, blood, and
fresh frozen plasma) also are also efficient volume
expanders but are not easily available and may cause
sensitivity reactions and other complications.
MONITOR CAREFULLY DURING FLUID THERAPY

63. If improvement with fluid bolus at any stage:
Fluid responsive shock
 Give 70 ml/kg over 5 hours in infants and over 2½ hours in a
child with hypovolemic shock due to gastroenteritis
 Start maintenance fluid in case of other conditions with
shock
SHOCK – EMERGENCY TREATMENT
FLUID BOLUS

64. FLUID BOLUS
If no improvement with fluids boluses or deterioration :
Manage as septic shock / cardiogenic shock
 Give maintenance IV fluid @ 4ml/kg/hour
 Add broad spectrum antibiotics
 Start Epinephrine infusion (0.1 to 1 mcg/kg/min).
Use dopamine infusion at 10 mcg/kg/min if epinephrine
not available
SHOCK – EMERGENCY TREATMENT

65. If no improvement with fluids boluses or deterioration :
 Give first dose of steroids if adrenal insufficiency
suspected / COVID strongly suspected or confirmed
 Consider transfer to facility with ICU settings for further
work-up
SHOCK – EMERGENCY TREATMENT
FLUID BOLUS

66. When signs of shock are detected, rapidly administer a fluid bolus of 10-20
ml/kg of isotonic crystalloid solution (RL/NS over 30-60 minutes).
Fluid administration rate should be individualized for each patient based on
frequent clinical assessment (pulse rate, capillary refill, breathing rate)
before, during and after fluid therapy is given.
SUMMARY OF INITIAL FLUID THERAPY IN
SHOCK

67. Placement of a 3-way stopcock in the IV tubing system can facilitate rapid fluid
delivery as fluids can be pushed by syringe.
Slower rate (over 60 min) is recommended for children who have febrile
illnesses, are malnourished and children with moderate to severe anaemia.
Once you have started fluid, assess for type of shock (hypovolemic,
distributive, cardiogenic and obstructive) which is critical to decide further
management.
SUMMARY OF INITIAL FLUID THERAPY IN
SHOCK

68. Chart 2.3: How to Give IV Fluids for Shock in a Child without Severe Acute Malnutrition
If
deterioration
(features
of
fluid
over
load
at
any
stage)
stop
fluid
bolus
and
start
maintenance
fluids
If improvement with fluid bolus at any stage:
Fluid responsive shock
• Give 70 ml/kg over 5 hours in infants and over 2 ½ hours in a
child with hypovolemic shock. Give additional fluids if losses
continue.
• Start maintenance fluid in case of other types of shock.
Reassess child
No improvement/No deterioration Improvement #
improvement
• Look for evidence of blood loss/
severe anemia:
give blood 20 ml/kg
Repeat bolus of 10 ml/kg over 30 min
(up to 2 bolus) *
If no improvement with 2 fluids boluses in sick looking child:
Fluid refractory shock
Manage as septic shock:
• Add broad spectrum antibiotics
• Start Epinephrine infusion (0.1 to 1 mcg/kg/min).
• Use dopamine infusion at 10 mcg/kg/min if epinephrine not
available
• If no response, give IV hydrocortisone if adrenal insufficiency is a
possibility (1-2 mg/kg)
• If still poor response/prolonged or high dose of vasopressors
required, consider transfer to facility with ICU settings, if available
No improvement

69. - Give Oxygen
- Give 5 ml /kg of 10% Dextrose
- Put IV line
- Give half normal saline in 5% Dextrose* Over 1 hr.
- Monitor RR/PR every 5-10 Minutes
* Use R/L if Half NS not available
Fluid responsive
Continue rehydration with 5-10 ml/kg /hr. ORS
alternating with starter diet ( F-75) over 10-12 hours
If Fluid unresponsive – IV maintenance fluid ,
Vasopressors , Steroids , Blood
HOW TO GIVE IV FLUIDS FOR SHOCK IN A
CHILD WITH SAM

70. A child with SAM with cold extremities with CRT>3 seconds
and weak & fast pulse
• Give oxygen to keep SpO2 >94%
• Insert an IV line (draw blood for emergency laboratory investigations)
• Weigh the child (or estimate the weight) to calculate the volume of fluid
• Give 5 ml/kg 10% Glucose IV
• Give IV fluid 15 ml/kg over 1 hour of either half-normal saline with 5% glucose or Ringer’s lactate in 5% glucose*
Switch to oral or nasogastric
rehydration with ORS, 10 ml/kg/h up
to 10 hours in alternate hour with
starter diet (F-75)
• Add broad spectrum antibiotics
• Start Epinephrine infusion (0.1 to 1 mcg/kg/min). Use dopamine infusion at 10 mcg/kg/min if epinephrine not available
• If no response, give IV hydrocortisone if adrenal insufficiency is a possibility (1-2 mg/kg)
• If still poor response/prolonged or high dose of vasopressors required, consider transfer to facility with ICU settings, if
available
As soon as child is stabilized start feeding
Chart 2.4: How to Give IV Fluids for Shock in a Child with Severe Acute Malnutrition
*If profuse diarrhoea (more than 10 loose watery stools in last 24 hours), repeat 15 ml/kg of fluid over 1 hour
**The purpose of giving a diuretic during a blood transfusion is to prevent congestive heart failure from overloading the circulation with the transfusion.
Assume
The child has septic shock
If the child deteriorates, during the IV rehydration (RR increases
by 5 /min or PR by 15 beats/min), Stop the infusion and reassess.
Measure the pulse, respiratory rate, temperature and CRT at the start and every 10 min
Signs of improvement
(PR and RR fall)
If the child fails to improve after the
first 15 ml/kg IV over 60 minutes

71. Assess Child for Coma and Convulsions
To assess level of consciousness of a child, a simple scale
(AVPU) is used.
A Is the child Alert? If not,
V Is the child responding to Voice? If not,
P Is the child responding to Pain?
U The child who is Unresponsive to voice (or being shaken) AND to pain is
considered Unconscious.
A child who is not alert, but responds to voice, is lethargic.
An unconscious child may or may not respond to pain.
A child with a coma scale of “P” or “U” will receive emergency
treatment for coma.

72. ETAT: Convulsions/Coma
Emergency Signs
• Unconscious
• Convulsing now
EmergencyTreatment
• Manage airway
• Give oxygen
• Rectal diazepam if convulsion
• Give i.e. dextrose 10%
• Position the child

73. Treatment of Coma and Convulsions
Position the unconscious child  Turn the child on the side to
reduce risk of aspiration
 Keep the neck slightly extended
and stabilize by placing the cheek
on one hand
 Bend one leg to stabilize the body
position
 If trauma is suspected:
- Stabilize the child while lying on
the back.
- Use the “log roll” technique.

74. Treatment of Coma and Convulsions
 Turn the child to his/her side and clear the airway (A recovery position).
 Give 0.5 mg/kg diazepam injection solution PR;flush the catheter, after giving the drug.
 Check for low blood sugar.
 Give oxygen.
 If convulsions have not stopped after 10 minutes repeat diazepam dose.
Dosages of diazepam
Rectal diazepam
10 mg/2 ml
Intravenous diazepam
10 mg/2 ml
Age / weight 0.1 ml/kg 0.05 ml/kg
2 weeks to 2 months (<4 kg) 0.3 ml 0.15 ml
2 - <4 months (4 - <6 kg) 0.5 ml 0.25 ml
4 - <12 months (6 - <10 kg) 1.0 ml 0.5 ml
1 - <3 years (10 - <14 kg) 1.25 ml 0.60 ml
3 - <5 years (14 – 19 kg) 1.5 ml 0.75 ml

75. Management Algorithm for Status Epilepticus
 Establish ABCs: Establish IV access, draw blood for laboratory
investigations
 Give IV glucose if hypoglycemia or blood sugar could not be tested
 Monitor vital signs, Spo2
 Give IV calcium in infant <3 months
IV diazepam 0.3 mg/kg or IV lorazepam 0.1mg/kg (max 4mg/dose)
(If no IV access - PR diazepam 0.5 mg/kg or buccal/nasal/IM midazolam 0.2 mg/kg)
Repeat Diazepam once more if seizure continues (5-10 minutes)
Seizure not controlled or recurrence
IV phenytoin 20 mg/kg (10 mg/ml solution prepared in NS & given slowly over 30 min)
(Consider transfer to PICU facilities)
IV valproate 20-40 mg/kg (1:1 diluted with NS) over 5-15 minutes or IV leveracetam (30-60 mg/kg)
OR
IV Phenobarbitone 15-20 mg/kg over 45-60 minutes
(Re-assess airway again; consider tracheal intubation,if the airway is compromised or the patient
develops respiratory depression)